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All  Inaugural  Dissertation 


on  the  Yellow  Fever 


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AN 


INAUGURAL  DISSERTATION 


ON    THE 

YELLOW  FEVER. 

SUBMITTED  TO  THE  PUBLIC  EXAMINATION  OF  THE 

JFACU^TY  OF  PHYSIC 

TENDER  THE  AUTHORITTSc^^F^THE  TRUSTEES  OF  COLUMBIA  COLLEGE, 
IN  THE  STATE  OF  NEW-YORK, 

The  Right  Rev.  BENJAMIN  MOORE,  D.D.  President  j 

FOR  THE  DEGREE  OF 

DOCTOR  OF  PHYSIC, 

On  the  8th  Day  of  November,  1803. 


BY  JAMES  R.  MANLEY,  M.  A, 

citizen  of  the  State  of  N,ew-York. 


NE  W-rORK\ 


Printed  by  T.  S;!*  J.  Swords,  Printers  to  the  Faculty  of  Physio 
of  Columbia  College. 

1803. 


.r^    "^ 


fO   'THE 

Medical  Students  of  Coliwibla  College. 

In  compliance  with  an  ordinance  of  this  College,  I  now 
present  to  the  Public,  as  an  Inaugural  Dissertation,  a  few 
remarks  upon  a  disease  till  lately  but  little  known  in  this 
country;  the  nature  of  which  we  have  unfortunately  been 
experimentally  taught  at  the  expense  of  the  lives  of  many 
of  our  most  valuable  citizens. 

The  subject  of  this  paper  is  one  which  has  afforded 
matter  of  considerable  speculation  to  all  classes  of  the  com- 
munity, but  particularly  to  Physicians,  who,  at  the  present 
day,  greatly  differ,  both  as  it  respects  the  origin  and  the 
Jireatment  of  Yellow  Fever. 

I  may,  by  many  peisons,  (whom  I  must  conceive  less 
candid  than  the  gentlemen  to  whom  this  is  addressed)  be 
deemed  guilty  of  detraction  on  the  one  hand,  and  arrogance 
on  the  other,  in  attempting  to  differ,  in  the  one  case,  from 
high  authorities,  and,  in  the  other  instance,  in  even  daring 
to  hazard  the  publication  of  a  single  idea  not  sanctioned  by 
popular  opinion.  A  blind  acquiescence  in  the  opinions  of 
men  of  acknowledged  ability,  is  an  evil  which  has  ever  been 
much  deprecated  by  liberal  men,  and  which  must  continue 


(     vi     ) 

St)  to  be  until  a  corrective  be  efFectually  applied.  This 
servile  attachment  is  a  proininent  feature  in  the  character 
of  professional  men  generally ;  but  it  is  more  observable 
among  medical  gentlemen  than  among  persons  of  any  other 
description;  and  it  seems  to  arise,  as  a  very  natural  conse- 
quence, from  the  manner  in  which  a  medical  education  is 
conducted.  Young  men,  upon  commencing  the  study 
of  the  SCIENCE  OF  LIFE,  think  it  not  prudent  to  indulge 
their  own  speculations  in  matters  of  so  much  consequence 
both  to  their  patients  and  themselves.  In  addition  to  this, 
they  are  sometimes  even  taught  to  distrust  the  evidence  of 
their  own  senses,  rather  than  suffer  them  to  give  birth  to 
an  opinion  which  would  militate  against  any  favourite 
theory.  Works  of  experienced  writers,  as  they  are  called, 
are  put  into  their  hands :  those  writings  are  filled  with  that 
kind  of  knowledge  Vv'hich  is  infinitely  above  the  compre- 
hension of  their  juvenile  capacities :  their  judgments  are 
matured  only  by  the  exercise  of  their  understandings ;  and 
ere  their  judgments  are  sufficiently  strong,  or  before  they 
dare  assume  that  independency  of  mind  which  alone  is  the 
necessary  effect  of  the  exercise  of  their  own  intellectual 
faculties,  they  are  deluded  by  the  plausible,  though  incor- 
rect, reasonings  of  ingenious  sophists.  They  admire  their 
productions;  they  respect  their  superiority  of  talents;  and 
thus  are  led  on,  from  one  degree  of  partiality  to  another, 
until,  finally,  ere  themselves  are  aware,  they  are  found  to  be 
zealous  advocates  for  systems  which  they  do  not  understand, 
and  practising  from  principles  deduced  from  mere  hypothe- 
ses grounded  upon  the  assumption  of  false  premises. 

It  is  this  over- weening  respect  for  the  opinions  of  great 
men  which  has  been  the  efficient  cause  of  the  comparatively 
slow  progress  of  medical  science,  and  it  is  this  which  will 
continue  to  retard  it  as  long  as  professional  pride,  divested 


(     vii     ) 

of  liberality  of  sentiment,  shall  glory  in  echoing  the  dogmas 
of  philosophic  tyrants.  Waving  all  further  remarks  on  the 
ill  consequences  which  result  from  servilely  adopting  the 
opinions  of  our  fathers,  I  shall  now  enter  particularly  on 
my  subject ;  fervently  wishing  that  the  example  of  the  Pro- 
fessors of  this  College  may  have  its  due  effect  upon  you. 
Gentlemen,  who  are  placed  under  their  guardianship,  in 
enabling  you  to  combat  this  error,  so  degrading  in  itself, 
and  so  injurious  to  the  cause  of  Medicine. 

JAMES  R.  MANLEY. 


AN 

INAUGURAL  DISSERTATION 


ON 


YELLOW  FEVER, 


x  ELLOW  Fever  has,  by  a  great  part  of  the 
medical  profession,  been  looked  upon  as  a  con- 
tagious disease:  I  shall  therefore  commence  this 
subject  by  an  examination  into  the  proof  v^hich 
supports  this  idea:  previous  to  which  it  will  be 
necessary  to  define  the  terms  infection  and  cojita- 
gion,  or  simple  and  specific  infection. 

Simple  infection  I  consider  a  certain  deleterious 
agent,  operating  upon  the  human  body,  through 
the  medium  of  our  atmosphere :  this  deleterious 
agent  being  the  product  of  natural  secretion  and 
excretion,  or  the  product  of  animal  and  vegetable 
decomposition,  depraved  by  the  combined  actioa 
of  fortuitous  causes,  such  as  a  want  of  cleanliness, 
of  free  ventilation;  an  unusual  degree  of  heat 
and  humidity,  &;c.  which  all  tend  to  produce  ^ 
high  grade  of  predisposition,  fitting  the  body  for 
the  pperation  of  the  usual  occasional  causes  of 

B 


"% 


10 

fever :  and  in  this  sense  all  diseases  may  be  said 
to  be  more  or  less  infectious. 

Specific  infection,  or  contagion,  I  consider  as  a 
morbid  material,  imparted  to  the  human  body 
either  by  actual  contact,  or  through  the  interven- 
tion of  our  atmospliere  :  this  material  being  the 
morbid  product  of  morbid  secretion  or  excretion^ 
producing  similar  disease  in  all  places,  in  all 
states  of  the  weather,  in  all  seasons  of  the  year, 
in  all  ages^  sexes,  and  constitutions. 

This  definition,  imperfect  as  it  may  be,  I  am 
disposed  to  think,  will  be  found  to  hold  true,  as. 
applied  to  small-pox,  measles,  scarlatina,  and  the 
whole  class  of  exanthematous  diseases,  which  are 
decidedly  propagated  by  specific  infection. 

We  do  not  find  that  the  plague  becomes  con- 
tagious before  the  inguinal  or  axillary  buboes, 
have  formed,  and  until  a  morbid  secretion  has 
actually  taken  place.  And  our  own  observations, 
upon  a  disease  till  lately  of  very  frequent  occur- 
rence, all  tend  to  confirm  the  truth  of  this  posi^ 
tion,  that  even  diseases  of  specific  infection  can- 
not reproduce  themselves  until  the  morbid  mate- 
rial which  first  excited  the  disease  shall  have 
exerted  such  an  influence  upon  the  system  as  shall 
have  caused  the  secretion  and  excretion  of  the 
same  active  matter  which  was  essential  to  its  ge- 
neration in  the  first  instance. 

We  fi^^nd  from  actual  observation,  that  the  dis- 
^atses  just  above  mentioned,    though  assuredly 


ii 

Specifically  infectlouSj  never  prove  so  until  tht 
morbid  secretion  w^hich  characterises  all  conta- 
gious diseases  has  made  its  appearance. 

The  Yellow  Fever  has  likewise  been  viewed  as 
a  disease  exclusively  imported;  and,  unfortunate- 
iy^  those  who  have  embraced  this  opinion  have 
also  considered  it  as  specifically  infectious^  mak- 
ing the  morbid  secretion  and  excretion,  which  are 
the  essential  characteristics  of  contagioji,  either 
the  yellowness  of  the  skin,  or  the  matter  of  black* 
vomiting ;  neither  of  which  will  be  found  true, 
since  it  proves  fatal  in  many  instances  when  nei- 
ther of  these  symptoms  is  present. 

If  Yellow  Fever  were  a  disease  of  specific  in- 
fection, it  should  certainly  be  possessed  of  one 
symptom  characteristic  of  itself,  as  all  contagious 
diseases  have  such  symptoms.  The  pathogno- 
monic symptoms  of  small-pox,  measles,  scarla- 
tina, &c.  are  very  evident.  Now,  if  we  were 
disposed  to  favour  the  idea  of  the  specific  nature 
of  Yellow  Fever,  where  should  we  find  a  symp- 
tom which  should  designate  it  particularly?  We 
should  not  be  able  to  distinguish  it  by  the  fiavidity 
of  the  skin;  for  this  is  no  uncommon  symptom 
in  many  febrile  diseases,  and  almost  invariably 
accompanies  protracted  cases  of  common  tertian 
intermittents  in  this  country:  and  the  matter  of 
black-vomiting,  to  be  made  pathognomonic  in 
this  disease,  should  always  mark  this  form  of 
fever,  and  never  occur  in  diseases  of  any  other 


m 

descriptiori.  And  further,  we  can  by  no  means 
allow  either  of  these  cardinal  symptoms  to  ht 
the  product  of  any  morbid  change  which  has 
taken  place  in  any  of  the  circulating  fluids  of  the 
system. 

Again:  if  it  were  a  fever  of  a  specifically  in- 
fectious nature,  it  should  reproduce  itself  in  all 
places,  in  all  persons,  and  in  all  states  of  the 
atmosphere;  we  should  observe  it  extending  its 
sphere  of  action  in  the  winter  season  as  well  as 
in  summer ;  we  should  find  it  epidemic,  when 
once  produced,  in  the  most  northern  latitudes^ 
and  always  generating  identical  disease  :  But 
experience  teaches  us  the  contrary;  and  the  same 
causes  which  are  adequate  to  its  production  in 
warm  southern  climates,  must  acquire  a  much 
greater  degree  of  intensity  to  generate  a  fever  of 
the  same  type  in  this  or  any  more  northern 
country. 

Plague,  when  carried  to  Moscow,  progressed 
by  immediate  specific  infection ;  and  bubonic 
plague  would  become  epidemic  in  the  same  man- 
ner, whether  in  the  torrid  latitude  of  Gambia,  or 
in  the  frozen  regions  of  Zemhla.  Dare  any  per- 
son risk  the  same  assertion  of  Yellow  Fever? 
He  certainly  might  with  the  greatest  safety, 
having  once  established  the  identity  of  the  two 
diseases. 

That  the  disease  under  consideration  may  be 
imported  is  very  possible,  nay,  probable ;  but  it 


is  not  necessary,  in  order  to  believe  this,  that  Vv^fe 
should  call  in  the  aid  of  contagion.  We  can 
easily  conceive  that  a  fever  contracted  in  the 
AYest-Indies,  from  exposure  to  mere  vicissitude 
of  weather,  independent  of  the  auxiliary  causes 
which  there  always  exist,  shall,  in  a  passage  of 
three  or  four  weeks,  in  the  confined  air  of  a  small 
vessel,  reproduce  analogous  disease  in  others  * 
iiot  from  the  specific  nature  of  the  disease  itself, 
but  from  the  simply  infectious  nature  of  it,  in 
common  with  all  others,  when  favoured  by  the 
concurrence  of  external  causes.  Again :  the 
diseases  so  produced  shall,  in  the  confined  apart- 
ments of  sailors'  booths,  in  low,  exposed  and 
naturally  unhealthy  situations  of  a  city,  become 
auxiliary,  though  not  strictly  exciting  causes  of 
similar  diseases;  which  again  shall  differ  in  pro- 
portion to  the  intensity  of  the  causes  which  co- 
operate with  the  first  simple  infection.*  The 
experience  of  every  year  would  seem  to  confirm 
the  truth  of  this  opinion:  and  if  we  should  ob- 
serve that  autumnal  fevers  difiFer  as  the  causes 
which  produce  them  are  more  or  less  powerful ; 
and  if  we  should  further  observe,  as  we  all  must 


*  The  propriety  and  usefulness  of  quarantine  establishments,  in  all 
sea-port  towns,  not  only  with  a  view  to  guard  against  diseases  strictly- 
contagious,  but  also  to  prevent  the  introduction  of  disease  in  the  above 
manner,  fully  appears  from  the  foregoing  paragraph ;  and  surely  qua- 
rantine law  should,  from  the  single  circumstance  of  its  obviating  possible 
evil,  meet  with  the  sanction  of  all  legislative  bodies,  in  ail  places  where 
reasonable  apprehension  ean  be  entertained. 


14 

jobserve,  if  not  blinded  by  pre-coneeived  opinion^ 
that  Yellow  Fever  is  a  variety  of  autumnal  fever, 
arising  from  the  action  of  concentrated  causes 
upon  high  degrees  of  predisposition;  would  not 
an  argument  be  furnished  which  should  pointedly 
oppose  the  idea  of  contagion? 

If  it  w^ere  contagious,  how^  should  w^e  account 
for  the  different  appearances  which  it  assumes  in 
different  states  of  the  weather^  and  upon  different 
constitutions?  And  it  certainly  is  a  fact  well  au- 
thenticated, that  the  mildest  intermittents  of  our 
country  do  degenerate  into  this  form  of  disease,  in 
such  situations  as  are  favourable  to  the  propaga- 
tion of  it.  In  what  way  can  we  reconcile  these 
-things  with  the  specific  nature  of  the  disease  in 
question? 

It  has  appeared  in  the  interior  of  our  country, 
some  hundreds  of  miles  from  any  sea-port  town, 
in  places  totally  inaccessible  by  w^ater.  If  it 
were  contagious,  we  must  presume,  upon  the 
truth  of  one  or  both  of  these  circumstances,  ei- 
ther that  the  disease  existed  there  from  time 
immemorial,  or  that,  notwithstanding  the  inland 
situation  of  the  country,  it  has  there  been  carried^ 
concentrated,  and  condensed  in  materials,  ca- 
pable of  retaining  the  specific  matter  of  infec- 
tion; neither  of  which  opinions  are  sufficiently 
supported  to  w^arrant  their  belief:  but,  on  the 
contrary,  where  it  has  so  appeared,  it  has  always 
been  found  to  originate  from  local  causes,  and  to 


15 

progress  or  abate,  both  as  respects  the  number 
of  its  victims  and  the  violence  of  its  symptoms^ 
m  proportion  as  the  causes  first  producing  it  ex- 
isted in  a  greater  or  less  degree. 

Having  said  thus  much  in  endeavouring  to  dis- 
prove the  contagious  nature,  as  also  the  foreign 
origin  of  Yellow  Fever,  I  shall  conclude  this 
part  of  my  Essay ;  fervently  wishing,  if  it  be 
possible,  that  those  gentlemen  who  still  advocate 
the  doctrine  of  contagion  and  importation,  would 
divest  themselves  of  pre-conceived  opinions,  un- 
biassed by  favourite  writings,  discriminate  be^ 
tween  speculative  and  experimental  reasoning, 
and  candidly  examine  the  validity  of  the  evidence 
which  supports  either  opinion.  It  is  much  to 
be  regretted  that  medical  writers  have  suffered 
their  trifling  party  differences  to  thwart  their 
judgments  in  a  matter  of  so  much  consequence 
to  the  public  as  the  subject  now  before  us:  for 
it  would  appear  that  the  opposition  made  to  a 
doctrine  so  satisfactory^  and  so  very  adequate  to 
the  explanation  of  the  disease,  is  to  be  attributed 
to  a  want  of  that  conciliating  spirit  which  should 
always  characterize  professional  writings. 

The  disease  which  is  the  subject  of  this  Essay 
i'3  thus  marked  in  its  invasion,  progress  and  ter- 
mination:— It  is  ushered  in  by  a  great  degree  of 
languor,  listlessness,  want  of  recollection,  and 
disinclination  to  all  kinds  of  active  exertion;  to 
which  soon  succeeds  the  febrile  shivering,  which 


^  16 

again  having  continued  an  indefinite  period  of 
time,  is  followed  by  an  intense  degree  of  heat — i 
quickened  and  laborious  respiration^ — pulse,  for 
the  most  part,  frequent,  full,  hard  and  throb- 
bing—skin dry — tongue  whitish  and  moist,  hav- 
ing an  appearance  peculiar  to  diseases  of  mem- 
branous inflammation— bowels  generally  costive, 
great  oppression  at  the  precordia,  attended  also 
with  acute  pains  of  the  head,  back  and  loins, 
with  a  suffusion  of  the  whole  countenance,  but 
particularly  of  the  eyes.  In  this  state  of  the  dis- 
ease the  patient  is  restless,  sleeps  little,  and 
awakes  vv^ithout  being  refreshed;  the  thirst  also, 
from  the  first  invasion  of  the  disease,  being  ex^ 
cessive.  These  symptoms,  if  not  relieved,  only 
prove  to  be  the  precursors  of  another  set  of 
symptoms  infinitely  more  dangerous,  and  to 
which  the  assistance  of  the  physician  can  afford 
very  little  relief.  The  pulses  sink;  they  become 
weak,  very  frequent,  and  often  intermittent.  The 
state  of  the  tongue  is  infinitely  more  alarming, 
having  changed  from  a  whitish  colour  to  one  al- 
most approaching  to  black.  The  redness  of  the 
countenance  generally,  and  eyes  in  particular, 
is  now  followed  by  a  yellow  colour.  The  whole 
body  often  takes  on  the  same  appearance.  The 
vomiting,  which  at  first  was  by  no  means  very 
alarming,  now  becomes  incessant,  and  the  mat* 
ter  ejected,  which,  in  the  first  instance,  was  the 
natural  contents  of  the  stomach,  appears  now  to 


It 

be  the  effect  of  a  morbid  change  having  taken 
place  in  that  organ.  Hemorrhages  from  the 
nose  and  mouth  are  not  unfrequent.  The  pa- 
tient is  by  turns  sensible  and  delirious.  Sub- 
sultus  tendinum,  and  coldness  of  the  extremities, 
now  succeed,  when  the  patient  may  be  said  to 
be  struggling  with  death,  which  unfortunately 
soon  follows. 

These  are  the  symptoms  of  the  disease,  as  it 
commences  and  proceeds  on  to  a  fatal  termina- 
tion in  the  greater  number  of  cases ;  though  it 
can  scarcely  be  said  that  any  of  the  symptoms 
which  here  mark  the  latter  stage  of  the  disease 
are  constant  and  invariable.  The  symjptoms  of 
vomiting  and  delirium  are  very  generally  vica^ 
rious ;  and  the  flavidity  of  the  whole  body  is  by 
no  means  so  constant  an  attendant  upon  the  dis- 
ease as  the  yellowness  of  the  eye.  Indeed,  the 
symptoms  which  generally  distinguish  it  greatly 
differ  in  degree,  and  this  difference  is  commonly 
found  proportionate  to  the  intensity  of  the  con;?- 
bined  causes. 


CAUSES, 

I  COME  now  to  consider  the  causes  which 
have  been  found  adequate  to  the  production  of 
this  disease,  at  different  times,  for  years  past, 
both  in  this  country  and  in  the  West-Indies» 

C 


18 

If  we  take  a  candid  survey  of  the  works  of 
those  gentlcQien  who  have  written  professedly 
on  the  diseases  of  warm  cHmates,  we  shall  find 
demonstrative  proof  of  its  local  origin  wherever 
it  made  its  appearance.  If  we  look  into  the  dif- 
ferent medical  publications  in  this  country,  the 
result  of  our  researches  will  be  the  same.  Phy- 
sicians of  eminence,  in  many  parts  of  America, 
have  instituted  inquiries  on  this  subject,  and  the 
result  of  those  inquiries  has  been  what  we  might 
have  expected  from  reasoning  a  priori  on  the 
nature  of  the  disease. 

It  is  remarked  by  those  physicians  who  have 
treated  on  this  subject,  that  when  it  does  appear, 
it  always  succeeds  great  moisture,  in  that  season 
of  the  year  in  which  the  sun  exerts  its  greatest 
influence;  and  although  many  of  them  contend 
for  the  specific  nature  of  the  disease,  we  observe 
in  all  their  writings  this  remarkable  coincidence 
laid  down;  a  proof  that  the  one  is  necessary,  and 
the  other  indispensibly  requisite  in  the  production 
of  that  vitiated  state  of  the  atmosphere  to  which 
Yellow  Fever,  as  it  has  appeared  in  the  sea-ports 
of  the  United  States  and  in  the  West-Indies,  is  to 
be  wholly  attributed.  To  this  it  may  be  objected, 
that  in  the  autumnal  season  of  the  years  1791, 
1793,  1795,  and  1797,  rain  did  not  fall  in  greater 
quantity  than  is  usual  in  warm  weather ;  not- 
withstanding which  this  disease  appeared  among 
us.     But  it  is  to  be  recollected,  that  the  slips. 


1^ 

wharves,  and  low  and  filthy  situations  of  many 
parts  of  our  city,  furnished  every  thing  essential 
to  the  production  of  this  pestilential  effluvium; 
and  it  was  to  the  locality  of  the  cause  alone  that 
we  are  to  impute  the  comparatively  small  number 
of  its  victims  in  those  seasons.* 

It  would  be  needless  for  me  to  multiply  autho- 
rities in  support  of  the  endemial  origin  of  this 
disease.  Dr.  Rush,  in  his  treatise  on  the  Yellow 
Fever,  as  it  appeared  in  Philadelphia,  in  the  year 
1793,  has  placed  this  matter  in  a  very  clear  point 
of  view,  as  respects  that  place ;  and  our  own 
observations  in  the  year  1798,  in  this  city,  per- 
fectly coincide  with  those  laid  down  by  writers 
on  the  causes  of  fevers  in  warm  climates:  and  if 
analogical  reasoning  may  be  admitted,  we  can  no 
longer  doubt  its  indigenous  origin.  The  banks 
of  the  Ganges,  the  Indus,  and  the  Nile,  are  all 
visited  with  analogous  diseases,  when  the  waters 
which  inundated  their  respective  countries  have 
begun  to  subside,  and  their  muddy  shores  are 
exposed  to  the  direct  rays  of  a  scorching  sun  : 
and  the  fatality  of  disease  in  the  islands  of  Suma- 
tra and  Java  is  justly  attributed  to  the  same  cause. 
In  addition  to  this,  the  writings  of  Lind,  Jack- 
son, Mosely,  and  others,  might  be  adduced  to 


*  Vide  an  Essay,  inserted  in  the  Medical  Repository,  vol.  i.  p.  315.  by 
Valentine  Seaman,  M,  D.  entitled,  Jn  Inquiry  into  the  Cause  and  Preva- 
lence of  the  Tellonx)  Fever  in  New-Tork,  in  1795.  See  also  a  Report  made 
by  a  Committee  of  the  Medical  Society  of  this  State,  in  January,  1799. 


20 

prove  the  absolute  power  of  vegetable  and  animal 
decomposition  to  produce  the  most  violent  and 
dangerous  febrile  diseases. 

Whether  the  vitiated  atmosphere,  thus  gene^ 
rated  by  the  action  of  the  sun  upon  animal  and 
vegetable   materials   capable  of  decomposition, 
be  merely  the  predisponent  or  the  exciting  cause 
of  this  disease,  I  judge  not  necessary  to  answer; 
though  I  should  suppose  that  this  will  differ  ac- 
cording to  the  situation  of  the  patient  previous  to 
the  invasion  of  disease.     Any  agent,  capable  of 
inducing  a  great  degree  of  debility,  may  become  a 
predisponent  cause:  accordingly,  excessive  heat, 
fatigue  consequent  upon  m.ental  or  bodily  exer^ 
tion,  fear,  grief,  intemperance  in  eating,  frequent 
intoxication,    the  application  of  cold,  and  the 
subduction  of  accustomed   stimuli,  are  all  laid 
down  by  authors  as  predisponent  causes  of  the 
disease,  though,  at  the  same  time,  no  person  can 
doubt  the  capability  of  any  one  of  these  causes 
to  excite  the  disease,  when  operating  upon  pre* 
disposition  already  formed.     From  continued  ac- 
tion the  predisponent  may  become  the  exciting 
cause.    Thus  a  vitiated  atmosphere,  independent 
of  any  other  cause  capable  of  being  detected  by 
our  senses,  may  become,  and  I  have  no  doubt 
does   become,    efficient    to    the   production   of 
Yellow  Fever. 


21 


TREATMENT. 

FROM  the  consideration  of  the  symptoms  of 
this  disease,  in  all  its  different  stages,  the  first 
indication  which  would  present  itself  would  be 
to  moderate  the  excessive  excitement  of  the  sys- 
tem. 

II.  To  obviate  the  occasional  causes  of  fever. 

III.  To  prevent  or  remove  the  danger  of  the 
system  falling  into  a  state  of  great  debility. 

The  first  indication  would  be  answered  by, 

1.  Blood-letting. 

2.  Mild  cathartic  medicines. 

3.  Cool  air—cool  water,  externally  applied, 
and  internally  exhibited  with  acids. 

4.  A  temporary  suspension  of  the  exercise  of 
the  senses. 

5.  Blisters,  applied  to  those  parts  most  liable 
to  be  injured  by  the  increased  action  of  the  ar- 
terial system. 

I  am  well  aware  that  the  propriety  of  blood- 
letting in  this  disease  has  been  much  questioned; 
but  I  am  very  much  inclined  to  think  that  the 
prejudice  against  this  point  of  practice  has  arisen 
from  the  two  general  and  promiscuous  use  of 
the  lancet. 

Those  gentlemen  who  so  strenuously  oppose 
blood-letting,  are,  notwithstanding,  great  advo- 
cates for  the  old  sudorific  plan  of  treatment.  Now 


122 

tills  sudorific  plan,  with  them,  is  intended  to  an- 
swer the  double  purpose  of  eliminating  from  the 
system 'the  morbid  material  which  generates  the 
disease;  while,  at  the  same  time,  it  serves  to 
moderate  the  action  of  the  sanguineous  system. 
If  so,  the  event  of  both  methods  would  be  pre- 
cisely the  same:  but  as  respects  the  operation 
of  the  remedies,  in  my  view  there  would  be  an 
essential  difference.  In  the  one  case  the  excita- 
bility of  the  system  will  be  alm.ost  exhausted 
by  the  administration  of  medicines  to  force  a 
perspiration^  which  can  by  no  means  prove  cri- 
tical, since  the  means  used  defeat  the  very  end 
for  which  they  are  intended:  whereas,  in  the 
other  case,  we  observe  that,  when  venesection 
has  been  premised,  perspiration  is  almost  the  im- 
mediate consequence  of  the  application  of  tepid 
bathing,  or  even  cool  air;  and  this  perspiration 
will  be  found  to  be  infinitely  more  beneficial  to 
the  patient  than  that  induced  by  stimulating  me- 
dicines and  vinous  drinks,  since  it  is  not  followed 
by  any  considerable  exhaustion  of  strength,  it 
being  the  immediate  eflfect  of  the  subduction  of 
heat ;  v/hile,  in  the  other  instance,  it  is  altogether 
caused  by  excessive  stimulation,  w^hich  vv^e  wish 
as  much  as  possible  to  avoid. 

But  the  greatest  objection  alleged  against  this 
practice  is,  that  it  induces  a  degree  of  debility  very 
dangerous  to  the  patient,  and  very  difficult  to  re- 
move,    A  question  might  here  be  asked  which 


23 

experience  only  must  answer — which  of  the 
afore-mentioned  remedies  induces  the  greatest 
deo-ree  of  exhaustion?  And  here,  as  in  all  other 
m.edical  disputations,  the  comparative  merits  of 
each  mode  of  treatment  should  be  settled  by  the 
comparative  success  of  each  practice. 

The  occurrence  of  hemorrhage  in  this  disease 
is  not  very  unusual;  nay,  it  is  a  common  circum- 
stance.    If  these  hemorrhages  are  active  in  some 
patients,  no  person  can  doubt  the  propriety  of 
venesection  in  such  particular  cases;  and  if  pas- 
sive,   they  must  occur   from    indirect   debiHty, 
which  is  the  effect  of  excessive  excitement.     If 
we  obviate  this  excessive  excitement,  we  of  ne- 
cessity prevent  this  dangerous  state  of  indirect 
debility;  and  in  doing  this  we  do  nothing  more 
than  anticipate  an  evacuation  which,  in  all  pro- 
bability, will  take  place:  and  were  this  the  only 
good  effect  arising  from   its  use,  it  would  cer- 
tainly be  more  safe  to  hazard  the  subduction  of  a 
definite  quantity  of  blood,  than  to  risk  the  event 
of  passive  hemorrhage;  m^ore  especially  since,  by 
this  means,  we  accelerate  a  recovery  which  else 
would  be  tedious,  painful  and  protracted  :  we  fit 
the  system  for  the  after  operation  of  other  reme- 
dies, and  relieve  ourselves  from  all  fears  of  con- 
gestion or  effusion  in  parts  essential  to  life. 

It  has  been  ascertained,  from  the  dissections 
of  persons  who  have  died  of  this  disease,  that, 
in  very  many  instances,  some  of  the  viscera  were 


24.      ^ 

congested,  and  effusion  had  taken  place  in  others  5 
as  also  that  the  membranes  immediately  investing 
those  organs  had  taken  on  an  inflammatory  ap- 
pearance. Surely  such  circumstances  justify  the 
propriety  of  blood-letting,  and  call  loudly  for 
the  exercise  of  the  lancet  as  an  essential  point  of 
practice. 

In  thus  speaking  of  blood-letting,  I  would  not 
be  understood  as  approving  it  in  all  cases  of 
this  disease.  I  only  wish  to  recommend  its  more 
general  use,  and  to  check,  if  possible,  that  torrent 
of  obloquy  which  has  been  so  illiberally  poured 
upon  those  physicians  who  have  given  into  this 
practice. 

In  evacuating  the  first  passages  it  will  be  pro- 
per always  to  have  in  view  the  state  of  the  sto- 
mach, whether  it  be  sufficiently  retentive  to  ad- 
mit of  the  exhibition  of  stimulant  medicines:  if 
it  be  not,  we  should  by  no  means  hazard  the  ad- 
ministration of  a  remedy  which  would  tend  to 
invert  its  action— the  inverted  action  of  this  or 
gan  being  one  of  the  most  formidable  symp- 
toms with  which  we  have  to  contend:  notwith- 
standing which  caution,  it  would  be  proper,  in 
the  first  stage  of  the  disease,  before  the  stomach 
is  materially  affected,  to  exhibit,  in  addition  to 
the  neutral  salts  usually  prescribed,  calomel  in 
proper  doses,  which  will  then  answer  the  dou- 
ble intention  of  evacuating  the  stomach  and  in» 
testines  at  the  same  time  that  it  would  relieve 


25 

the  disease  by  inducing  a  new  irritation,  and, 
by  increasing  the  action  of  the  absorbent  system, 
free  the  patient  from  the  dangerous  consequences 
of  congestion  or  effusion  in  any  vital  organ.  If 
the  second  intention  of  this  medicine  cannot  be 
answered  in  this  way,  it  may  be  used  in  the 
manner  recommended  by  Mr.  Clare,  and  also 
externally  applied  with  great  advantage.  The 
propriety  of  mercurial  medicines  in  this  disease, 
and  the  great  safety  with  which  they  may  be 
administered  in  its  most  desperate  forms,  will 
appear  from  the  practice  of  Dr.  Chisholm  in  the 
fevers  of  Grenada,  and  also  from  the  accounts 
given  of  it  by  the  most  eminent  physicians  irj 
this  country.* 

In  addition  to  the  mercurial  medicine  already 
named,  it  would  be  proper  to  exhibit  such  sa.- 
line  remedies  as  would  relieve  the  stomach  at  the 
same  time  that  they  proved  mildly  eccoprotic^ 
and  co-operated  with  the  bath  in  producing  per- 
spiration; and  the  medicine  best  calculated  for 
this  purpose  will  be  found  to  be  the  citrate  of 
pot-ash,  given  in  its  forming  state  (the  efferves- 
cing draught  of  Reverius) ;  the  carbonic  acid  air, 
extricated  during  the  formation  of  this  salt  in  the 

*  Vide  Rush's  Inquiries,  vol.  iii. — Brown's  Account  of  this  Fever  as? 
it  appeared  ii^i  Boston,  1798 — and  Stuart's  Inaugural  Dissertation :  from 
all  which  writings  it  would  appear,  that  when  calomel  had  exerted  its 
influence  upon  the  glaiidular  system,  so  as  to  have  induced  a  sensible 
ptyajism,  the  recovery  of  the  patient  was  almost  insured. 

D 


26 


stomach,  being  very  grateful  to  the  patient,  and 
very  effectual  in  checking  the  disposition  to  vo- 


miting. 


The  use  of  mild  enemata,  throughout  the  whole 
course  of  this  disease,  after  the  first  evacuations; 
have  been  premised,  is  a  point  of  practice  very 
piuch  and  very  properly  insisted  on.  The  supe- 
rior advantages  of  keeping  the  bowels  pervious 
by  this  method,  rather  than  by  the  exhibition  of 
cathartic  medicines,  when  the  stomach  is  so  re- 
markably irritable  and  irretentive,  will  appear  tq 
every  person  who  is  the  least  conversant  with 
the  disease  under  consideration. 

As  a  third  mean  of  moderating  the  inordinate 
action  of  the  arterial  system,  we  know  none  bet- 
ter calculated  than  the  admission  of  cool  air  to 
the  surface  of  the  patient,  the  exhibition  of  cool 
subacid  drinks,  together  with  the  use  of  cold- 
bathing.  All  authors,  with  great  propriety, 
agree  in  recommending  to  induce  perspiration  lu, 
all  febrile  diseases,  as  a  certain  mean  by  which 
to  fi'ee  the  system  from  that  extraordinary  quan- 
tity of  heat  which  is  the  essence  of  the  disease; 
and  from  actual  observation  it  has  been  ascer- 
tained, that  there  is  no  method  which  more  cer» 
tainly  produces  this  effect  than  bathing,  which 
has  this  decided  advantage  over  the  exhibition 
of  internal  remedies  (which,  by  the  bye,  are 
generally  antimonial  preparations),  that  its  tem= 


-27 

p'erature  can  always  be   suited   to  the  state  of 
the  patient,  and  the  manner  of  its  application 
may  be   varied   as   circumstances   shall    at    any 
time  seem    to    require :    whereas,   the   state   of 
the  patient's  stomach  often   renders  the  use  of 
internal  medicines  unavailing,  and  very  frequently 
injurious.     It  has   been  found    by  experiment, 
that  it  may  be  used  with  success  in  all  states  of 
fever,  except  at  its  immediate  invasion,  or  wdien 
the  patient  suffers  in   the  cold  stage  of  the  pa- 
roxysm: and  so  fully  satisfied  was  Dr.  Jackson 
of  its  efficacy,  that  he  insists  very  much  upon  its 
use  in  the  fevers  of  Jamaica;  Jind,  speaking  par- 
ticularly of  fever  as  it  prevailed  at  Savanna  La 
Mar,  he  has  these  remarkable  words:  "  It  should 
be  used  with  freedoni  and  with  boldness,  and  it 
is  the  remedy  on  which  we  must  principally  de- 
pend."*    Dr.  Rush  believed    it   to    be   a   very 
powerful  remedy  in  fevers,  from  witnessing  its 
efficacy  in  other  diseases,  and  found,  upon  ex- 
periment, that,  judiciously  applied,  it  answered 
his  most  sanguine  expectations^  and  that,  blood- 
letting excepted,  no  remedy  w^as  more  effectual 
in   reducing   the    excessive    excitement    of  the 
system.     And  Dr.  James  Currie,  of  Liverpool, 
has  clearly  established  its  safety  and  confirmed  its 
celebrity,  by  repeated  experiments  in  all  cases  of 
fever  which  came  under  his  observation.    I  deem 

*  Jackson  on  the  Fevers  of  Jamaica,  p.  223. 


m 

it  unnecessary  here  to  detail  the  particular  modes 
of  applying  water,  or  the  particular  temperatures 
of  baths,  as  applied  to  the  different  states  of  a 
patient.  For  a  more  minute  account  of  the  effi^ 
cacy  of  this  practice,  I  refer  my  readers  to  the 
invaluable  works  of  those  celebrated  authors  just 
mentioned. 

As  a  fourth  m^ean  to  answer  the  first  indica- 
tion, the  irritations  caused  by  impressions  made 
upon  the  organs  of  sense  are  to  be  avoided  as 
much  as  in  our  power,  and  particularly  those 
which  produce  disagreeable  sensations.  The  ex- 
ercise of  the  mind,  as  proving  directly  stimulant 
to  the  system,  should  be  very  sedulously  guarded 
against;  particularly  such  exercise  as  may  be  pro^ 
ductive  of  passion  or  emotion. 

For  the  same  reason  that  we  would  apply  epis* 
pasties  in  local  inflammatory  affections,  we  should 
use  them  in  the  first  stage  of  this  disease,  that  we 
may  not  only  have  the  benefit  resulting  from  their 
evacuations,  but  that  we  may  reap  the  advantages 
which  would  arise  from  their  action,  as  inducing 
new  and  more  powerful  irritations  in  the  parts 
contiguous  to  those  which  labour  under  actual 
or  partial  inflammation  from  the  operation  of  dis- 
ease. 

From  the  dissections  of  persons  who  have  died 
of  this  disease,  it  has  been  ascertained  that  the 
vessels  of  the  stomach  in  some  instances,  those 


!2^ 

of  tlie  hrain  in  others,  and  those  of  the  liver  iil 
many,  have  been  distended  with  blood,  and  have 
put  on  the  appearance  of  parts  having  undergone 
inflammation.  In  such  cases  the  application  of 
blisters  to  those  particular  parts  Vv^ould  have  been 
adviseable :  and  from  the  tendency  which  this 
disease  shows  to  spend  its  force  upon  one  or  other 
of  these  organs,  by  inflammation  and  its  conse- 
quences, it  would,  in  my  opinion,  not  only  be 
adviseable,  but  really  judicious  and  successful 
practice,  to  apply  blisters  in  the  early  stages  of 
ail  cases  of  this  disease^  before  the  hrain,  stomach 
or  liver  become  materially  affected;  at  the  same 
time  carrying  the  application  to  the  point  of  ul- 
ceration, that  they  may  serve  as  extensive  issues. 
But  in  the  more  advanced  stages  of  this  fever^ 
likewise,  the  application  of  cantharides,  with  a 
view  to  stimulate  the  patient,  and  render  his  sys- 
tem more  alive  to  the  operation  of  other  reme- 
dies, should  not  only  be  admitted,  but  insisted 
on  as  an  essential  part  of  the  cure;  and  for  this 
purpose  it  is  not  requisite  that  it  should  vesicate 
the  part  to  which  it  is  applied:  we  only  wish  to 
avail  ourselves  of  its  stimulus,  and  its  action  as  a 
rubefacient  fully  answers  our  purpose. 

The  treatment  which  shall  answer  the  second 
general  indication,  viz.  the  avoiding  the  occa- 
sional causes  of  fever,  may  be  laid  down  in  a 
very  few  words.     For  this  purpose  the  patient 


should  be  immediately  removed  from  such  situa- 
tions as  are  favourable  to  the  generation  of  dis- 
ease.    The  apartment    in   which   he   is   lodged 
should  be  as  spacious,  cleanly  and  well  ventilated 
as  possible.    If  this  be  impracticable,  the  utmost 
possible  care  should  be  taken  to  correct  the  at- 
mosphere   in    which    the   patient   is    immersed^ 
and  to  cool  it  by  artificial  means.     The  chamber 
of  the  patient  should   be  in  some  measure  co- 
vered with  powdered  quick-lime. _    The  bed  and 
body  linen  of  the  patient  should  be  frequently 
changed.     The  secretions  and  excretions  should 
be  kept  in  equllibrio,  lest  by  their  retention,  in 
the  one  case,  they  should  create  disagreeable  ir- 
ritations, or  by  their  profuse  evacuations,  on  the 
other  hand,  they  should  induce  a  dangerous  de- 
bility.    The  excrementitious  matters  of  the  pa- 
tient should  be  rapidly  and  carefully  removed  from 
his  room.     The  state  of  his  stomach  and  bowels 
should  be  strictly  attended  to,  and  plentiful  dilu- 
tion persisted  in ;  being  careful  that  nothing  be 
taken  into  the  stomach  as  food  that  cannot  be 
easily  assimilated  by  its   digestive  powers.     To 
these  may  be  added  the   injurious  application  of 
cold,  as  a  point  concerning  which  we  should  be 
very  solicitous.     By  attending  to  these  circum- 
stances we  shall,  in  a  great  measure,  obviate  the 
occasional  causes  of  fever. 

After  having  answered  the  two  first  indica- 


31 

tions,  procured  a  solution  of  the  fever,  and 
guarded  the  patient  from  the  danger  of  a  relapse, 
as  far  as  that  relapse  shall  depend  upon  the  ap- 
plication of  usual  causes,  I  come  now  to  the 
last  general  indication' — to  prevent  or  remove 
the  danger  of  the  system  falling  into  a  state  of 
great  debiJity.  The  operation  of  medicines,  in 
addition  to  the  action  of  disease,  must  certainly 
have  greatly  exhausted  the  natural  vigour  of  the 
patient.  To  prevent  this  exhaustion  of  strength 
being  over-proportionate  to  the  state  of  previous 
febrile  excitement,  requires  judicious  treatment 
in  the  first  stage  of  the  disease,  and  therefore 
would  more  properly  be  referred  to  the  first  in- 
dication. The  removal  of  this  state  of  debility 
is  that  which  more  particularly  appertains  to 
this  last  proposed  part  of  the  cure;  upon  which 
it  is  the  more  unnecessary  to  dwell,  since  it  is 
that  part  of  the  treatment  of  all  fevers  which  is, 
above  all  others,  best  understood.  I  shall  only 
pbserve,  that  the  exhibition  of  tonic  medicines 
to  patients  convalescent  from  this  disease,  I  be- 
lieve, is  not  so  generally  necessary  as  has  been 
usually  supposed;  the  recovery  of  persons  having 
once  commenced,  being  in  this,  as  in  most  other 
acute  diseases,  remarkably  rapid.  The  admi- 
nistration of  bark,  wine,  steel,  blisters,  cold-bath- 
ing, &c.  though  they  maybe  admitted,  in  many 
pases,  as  being  productive  of  benefit  to  patients. 


32 

may,  generally  speaking,  be  dispensed  with,  with- 
out incurring  any  hazard;  and  the  restoration  of 
the  patient's  strength  may  be  safely  trusted  to 
the  exhibition  of  a  nourishing  diet  of  easy  di-* 
gestion,    consisting   chiefly  of  farinaceous  food,  ; 

together  w^ith   the  use  of  milk    (which  is  ex-  | 

tremely  grateful  to  most  patients  at  this  period),  | 

moderate  exercise  in  the  open  air,  and  the  regi- 
men usually  observed  by  patients  convalescent 
WiH  febrile  disease. 


i 


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mo  2 

i  , 

C2B(239)M100 

■I         ^ 


!■        2> 


?**. 

I:ii 


